Health Business Blog

My perception is that doctors in previous generations were more likely to devote their entire lives (professional and “personal” time) to the practice of medicine. Today’s doctors are more likely to consider lifestyle and not automatically put everything into doctoring. This is partly cultural –as younger professionals in general have put more emphasis on balance– but a large part is structural, because residents are working fewer hours by law and because more doctors are working for others, which encourages an employee mentality.

I don’t really have a problem with doctors who want to have a life outside medicine, but overall I prefer to be treated by someone who’s really dedicated and wants to devote most of their waking hours to it. By the way I feel the same about other professionals I work with.

So I’d like to see some of the structural issues addressed to encourage those who want to go all out to do so. Kaiser Health News has an article on the topic today (Doctors Transform How They Practice Medicine), which gets at my point at least indirectly. The article discusses how physicians are opening “medical homes” to provide more coordinated care or opening concierge-style practices that limit the number of patients and charge extra fees.

Those are both kind of interesting but also a bit ho hum. I’d rather see a broader array of offerings including those that include more remote services and incorporate specialty care. I hope and think they’ll come because despite the fact that many docs are rushing into hospital employment, I believe many would rather work for themselves if there were a viable way to make it happen.

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By David E. Williams of the Health Business Group.

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It’s hard for policy wonks, politicians or health plans to be viewed credibly when promoting health care cost containment. Discussion quickly turns to “rationing,” and “death panels,” which no one wants to be associated with, and as a result the federal government has done almost everything possible to make sure cost effectiveness and overall costs are ignored in policy making.

Those closer to the action know better. In particular:

• Many costly treatments aren’t worth the money
• New treatments with tiny or no benefits often cost a multiple of existing therapies
• Despite their reputation for penny-pinching, health plans are often not aggressive in negotiating price
• Patients are already suffering mightily from high costs –and it impacts quality of life and survival as well as financial health
• Society as a whole can not afford to pay the high prices charged for so many of the new therapies

So it’s encouraging to see a perspective in the journal Blood endorsed by more than 100 experts. The piece, The Price of Drugs for Chronic Myeloid Leukemia (CML); A Reflection of the Unsustainable Prices of Cancer Drugs: From the Perspective of a Large Group of CML Experts,  is very useful because it comes from people who know what they’re talking about and who have traditionally been sympathetic to drug makers and unperturbed about costs.

Here are some excerpts that are noteworthy for their candor and clarity:

“If drug price reflects value, then it should be proportional to the benefit to patients in objective measures, such as survival prolongation, degree of  tumor shrinkage, or improved quality of life. For many tumors, drug prices do not reflect these endpoints, since most anti-cancer drugs provide minor survival benefits, if at all.”

…

“In the US, prices represent the extreme end of high prices, a reflection of a “free market economy” and the notion that “one cannot put a price on a human life”, as well as a failure of government and insurers to more actively negotiate pricing for anti-cancer and other pharmaceuticals, in contrast to practices in other parts of the world.”

…

“In Europe and many developed countries, universal health coverage shields patients from the direct economic anxieties of illness. Not so in the United States (US) where patients may pay an average of 20% of drug prices out-of-pocket(about $20-30,000 per year, a quarter to a third of an average household budget), and where medical illnesses and drug prices are the single most frequent cause of personal bankruptcies. High drug prices may be the single most common reason for poor compliance and drug discontinuation, and the reason behind different treatment recommendations in different countries.”

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By David E. Williams of the Health Business Group.

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A front-page Boston Globe article on a neurosurgeon suing a caregiver for a harsh blog post  is exciting but unrepresentative of the overall state of online doctor reviews. However it caused me to take another look at online physician ratings from the perspective of someone trying to find a doctor. Conclusion: we are still in the early days and there is plenty of opportunity for better, more useful information. It’s still difficult to use the sites for real decision making.

First I tried searching HealthGrades, Yelp, Angie’s List and Massachusetts Health Quality Partners (MHQP) for information on something I really care about. I typed in the name of a medical specialist at a local academic medical center who is caring for a family member with a serious illness. This doctor has been in practice for 20 years but only one site I looked at (HealthGrades) had any reviews, and those two were not detailed. I then looked for other specialists and found that there are typically very few reviews available. It’s unusual to find more than five reviews for a given specialist on any one site, although I’m sure there are some exceptions. MHQP doesn’t include specialists.

Next I turned to primary care. The information is better –MHQP in particular stands out on data quality– but there is still a lot to be desired. I searched for my physician, Dr. Johanna Klein of the Beth Israel Deaconess Medical Center’s Washington Square Group. Here’s what I found:

Healthgrades — a listing with a lot of publicly available information (address, phone, insurance, date of graduation) plus seven patient experience surveys showing that people generally like her

Angie’s List — which I paid $11 to join– has a confusing search function. I found Dr. Klein but no reviews for her. There were 16 reviews for the broader medical group, though, enough to get a general idea of the practice and some specific doctors within it. One of the reviews is harsh “I seriously question if she has actual medical training…” but most are pretty sober, boring and don’t sway me one way or the other. This site was the most disappointing overall and I don’t recommend subscribing.

Yelp –is the liveliest of the sites, at least in its reviews of this practice, and also incorporates some of the most innovative social media features. There are 7 reviews, 3 of which give 5 stars, 3 with 1 star and 1 with 2 stars. In addition to the rating most have a significant amount of text –quite a bit more than Angie’s List. Reviews are sorted by “Yelp Sort” as a default and can also be sorted by date, rating, Elites (a Yelp designation for evangelists) and Facebook friends. The Yelp sort takes into account various factors –like user votes and recency– to list the most helpful reviews first. Each reviewer has her or her first name, last initial, town and photo displayed, along with the number of Yelp friends, number of reviews posted and how many times they have “checked in” at the location. Clicking on the reviewer’s name provides a profile of the person, ratings of the usefulness of the person’s reviews, and a distribution of the person’s ratings. The distribution of ratings is interesting because it gets to a key concern physicians have about ratings: are they just posted by people with negative experiences?

The Yelp sort did an excellent job of ranking the ratings. The first review is by a person with multiple chronic illnesses who’s seen a specific doctor at the practice for 10 years and gave 5 stars. She had many specific things to report about her doctor and clearly had plenty of basis for her comments. Four people had rated the review helpful, and it showed that she had checked in twice on Yelp while at the practice (compared to none for the others).

The next two reviewers gave low ratings: 2 stars and 1 star. These reviewers have written more than 150 reviews each –awarding 4 or 5 stars in the vast majority of cases– so this is a helpful credibility builder for me.

The last 2 reviews –1 star each– are written by people with no Yelp friends and only a few reviews. The negative ratings are based on specific anecdotes and even though one has six “useful” votes it is still at the bottom, where I think it deserves to be.

Overall the reviews rung true to me based on my own experience.

MHQP is much more scientifically rigorous than the rest of the sites, and its data forms the basis for Consumer Reports’ recent report on physician quality in Massachusetts. Data on clinical quality comes from health plan data and patient experience is derived from a statewide survey. In patient experience there are 90 responses for the Washington Square Group. Results are also displayed as one to four stars, but here the stars have a statistical basis: e.g., 4 stars means an office did better than 85 percent of others in the survey, 1 star means it did worse than 85 percent of the offices. MHQP also enables a side-by-side comparison of different offices, which is a nifty feature.

Despite the harshness of some of the Yelp reviews of my practice the picture painted by the MHQP results are –if anything– worse. There are quite a few categories with 1 star (e.g., How well doctors give preventive care and advice) and few with 4. And yet 71 percent of the Washington Square Group’s respondents say they would “definitely” recommend their doctor and 19 percent say “probably.” Because of its statistical rigor the MHQP site is bereft of qualitative comments that could shed light on the findings, and results are reported at the level of the group rather than for individual physicians. And of course MHQP is only available in Massachusetts, although certain other states and regions have similar resources.

I looked at these websites when I picked my primary care physician. They didn’t have much influence on me then and wouldn’t today. In the end the number one issue was finding a specific physician I liked –and as mentioned there is essentially nothing documented on my doctor. Instead I relied on my previous doctor’s recommendation after eliminating a few other potential choices. Location was also important and I wanted someone within the Beth Israel system because I like the hospital and my records are on the PatientSite portal. I do have some concerns about the overall customer service of the practice and some of the low MHQP ratings, but figure if I watch out for myself that these things won’t affect me.

In an ideal world the rigor of MHQP ratings would be extended to the individual physician level –at least for certain measures– and to medical and surgical specialists. Physicians or practice manager would also have a way to reply to the ratings and reviews at least in a general way. If some of the Yelp approach could be applied to add texture to the data through user commentary then we’d really have something.

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By David E. Williams of the Health Business Group.

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The Saturday Evening Post has published a provocative article (How Doctors Die) by retired physician Ken Murray, making a strong case that over-treatment is rampant at the end of life. He describes anecdotes of physicians serenely accepting their death sentences and making the most of their last months and weeks compared with the average person who suffers needlessly and racks up a big bill in the process. Doctors understand the limitations of medicine in ways that typical patients don’t, he says, but have not been in a position to provide more appropriate care due to patient pressures, legal concerns, and the nature of the medical system. Hospice patients may live longer anyway, he adds.

I’m mainly on Dr. Murray’s side. I believe that over treatment is a big problem and that hospice care is underutilized. I understand the concept of never wanting to be put on life support. I am angered and saddened that the nonsensical “death panel” argument was used as a cudgel against ObamaCare by invoking the prospect of rationing of care.

And yet I’m uncomfortable with the article. First, to what extent should we accept the author’s anecdotes as evidence of the general state of physician perspectives? I don’t see a lot of systematic evidence for his contentions. Second, even if doctors feel that way should patients necessarily ratchet down their demands for services? I would say no.

My concern as a patient, caregiver or family member is about being written off when it’s not warranted. For example (since anecdotes seem ok, here) doctors discouraged a family member from chemo for leukemia due to his age, even though as I discovered the advice wasn’t really evidence based. He had chemo anyway thanks to our insistence, tolerated it well, and lived an extra year. It’s hard to figure out what tradeoff is reasonable to make between suffering and the potential to extend life even when all the information is in hand, which it rarely is.

And while it’s easy to oppose heroic, frequently futile measures and suffering in general, when it gets down to specific situations I’m not nearly as comfortable. Who’s to say a patient shouldn’t be willing to suffer in order to live a while longer and have a few more weeks or months with their grandkids?

The general point of the article –that those with the most knowledge of the limits and possibilities of medicine seek less of it than the general public in certain circumstances– is certainly worth contemplating. But I haven’t changed my own views after reading the piece.

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When I saw the MedPage Today headline, “Study: Docs in dark about complementary therapies” I assumed it meant that doctors didn’t understand these therapies. But the story described patients withholding information about what they were doing from their physicians. That’s not exactly a new or surprising finding.

The study advises physicians to ask about what else patients are taking or doing, which is probably a good idea. But I’d like to see more attention paid to how physicians react when they hear about other therapies and the extent to which they are willing or able to engage with the large percentage of patients that seek relief or cure outside the medical setting at the same time they are working with their doctors.

Some of these therapies are herbs or other substances that may interact with prescribed drugs. Doctors definitely need to know about that and deal with it. Other approaches, such as massage, meditation and reflexology may be helpful for some patients –and it may or may not matter if the physician is involved.

The best physicians take a personalized, holistic approach to their patients, and do so in ways that do not conflict with the evidence based mantra.  One physician I know has a medicine man (who’s also his patient) perform a ceremony blessing the statin he prescribes to another member of the same tribe. I’m willing to bet his patients are more adherent as a result of this approach.

I’m not a major proponent of alternative and complementary medicine, but I do find it revealing to see how physicians relate to other approaches, especially for diseases they can’t cure. Do they insist that other approaches are invalid and consider them an affront? Do they balance a healthy skepticism with open mindedness to the idea that they don’t know everything? Do they vary their approach depending on the individual patients and their situations?

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You should read Dr. Scott Gottlieb’s (The Doctor Won’t See You Now. He’s Clocked Out) opinion piece in the Wall Street Journal. He argues that ObamaCare is making independent physician practices obsolete by forcing physicians to work for big hospitals as part of Accountable Care Organizations (ACO), is  imposing high costs for information technology on those who try to remain independent, and that the Administration’s policies will have the ironic consequence of driving up costs since employed physicians are less productive.

There’s a lot of truth in the article. As I have written recently, fees sometimes rise when hospitals buy physician practices and tack on facility fees. And in my prediction for 2013 published by InformationWeek I predicted that physicians will struggle to stay independent.

But although I mainly agree with Gottlieb’s observations, I’m more optimistic than he is, and less eager to point the finger at ObamaCare. In particular:

• The trend toward hospital employment has been going on for a long while now, as Gottlieb acknowledges. One could say ObamaCare encourages this trend but from my perspective the bigger factors are the desire to join with a bigger entity to negotiate better rates with managed care, a generational shift as younger doctors decide they want balance between life and work (especially women, who now comprise the majority of medical students), and the rising overhead involved in running a practice. Ironically, physicians I’ve spoken with have cited the cost of health insurance for staff as a reason for joining up with the big boys!
• ObamaCare does not require anyone to be in an ACO and does not require them to be run by hospitals. Physicians could organize their own ACOs and I hope in the future more do, even if that hasn’t been the way things have gone so far
• Health IT is a drag on small office but also for big hospital based systems. Those inefficiencies will take a few years to work out but I’m optimistic that a new generation of systems will empower the small physician practice, the way technology has made it possible to operate smaller professional services firms in consulting, law and other fields
• Costs are becoming a bigger and bigger focus, and the country just won’t tolerate health care prices that go up and up. The facility fee issue and Steven Brill’s article in Time on costs are two examples. It’s commercial health plans, not government programs, that have been tolerating higher costs. Buying up physician practices may help hospitals negotiate hard with commercial health plans but Medicare and Medicaid are not going to be impressed. In the long run –maybe 10 years– hospital systems that fail to generate greater efficiency from buying up practices will lose ground to new types of entities, especially those that are virtually integrated through technology. As Gottlieb pointed out, we’ve been through the cycle of physician acquisition by hospitals before, and it was reversed due to lagging productivity
• ObamaCare represents a great big target to shoot at, and easy to criticize in a vacuum. But we have to compare it with what came before, which was hardly a panacea.

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Online doctor/patient relationships is the new frontier in social media. A report earlier this year discussed how medical boards would respond to different sorts of potentially inappropriate activity on social media. I asked Jeff Tangney, CEO of a professional online network for physicians called Doximity, to discuss the topic with me and to describe how Doximity fits in.

How widespread of a social media challenge are medical boards dealing with? Are there a lot of instances of doctors using social media inappropriately or is it relatively rare? 

Every profession adheres to a code of ethical behavior, but medicine carries an extra responsibility of safeguarding sensitive content, protecting patients and following privacy laws. Thus, the spotlight is cast on patient privacy violations conducted over social media, such as here and here. These instances are rare though, and state medical boards are now sensitive to these scenarios so that they can more quickly intervene. The “challenge” for physicians and medical boards is identifiying when, how and where social media technologies should be used to improve care delivery. Social media’s asynchronous and far-reaching properties are great tools for communication, continuous education and engagement beyond the 15-minute clinical appointment or physician phone call, and there are many physicians out there who will say that it’s had a very positive impact on their own practices.

What kinds of problems are typical?

Most problems can be traced back to HIPAA violations, such as improper de-identification of patient information or non-secure communication mediums.

Once the inappropriate behavior is pointed out, do the Gen Y doctors agree that it’s actually a problem, or do they disagree?

Tech-savvy Generation Y rode the first waves of social media as it crashed ashore, and in our experience most agree that embracing new efficient technologies can be done in a way that enhances and upholds the profession. Many young physicians choose to keep a Facebook profile, but they use privacy settings and know not to let it cross into their clinical practice, instead using tools like Doximity for professional conduct.

How have the norms changed over time?

The shift from in-person to online has been a slower one for the medical industry as a whole, but both patients and providers have grown to realize the real-time benefits of the right online or mobile technologies in information acquisition and secure communication. The greatest change in norm is increased familiarity and thus increased embrace.

How do patients feel about doctors’ online social networking behavior?

As patients ourselves, knowing that our physicians can have access to a national network of clinical experts right from their smartphone with a tool like Doximity is a technology milestone that we’re certain they should embrace.

What are the alternatives to general social networking sites? What are the pros and cons of using them? 

General social networking sites, while offering a large userbase, and not tailored for a specific industry like medicine, making it difficulty to find the right people to share with. Additionally, they often allow anonymity, which does not build a prerequisite level of trust for health conversations. Doximity is designed exclusively for health professionals, and each user’s identity is verified, thereby enabling an unprecedented level of collaboration around patient care.

Some well known sites, like Sermo, have fizzled. Why? 

Social media is a means to an end, not an end in itself. Doximity is the first secure network designed as a productivity tool by doctors, for doctors. Thus, even physicians that are too busy or too wary of common social media still choose to save time using Doximity’s national provider directory, mobile fax and secure messaging features.

How do you expect social networks for physicians to evolve over the next 5 years? Do you envision a role for doctor/patient interaction as well?

In the US healthcare system, patients on average see 19 different doctors in their lifetime, in the context of an industry approaching 20% of US GDP. It is clear that an interoperable, secure medical internet is critical, and Doximity’s growing platform and partners can streamline workflow and communication across the many participants in the system.

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Interview conducted by David E. Williams of the Health Business Group.

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A new study purports to demonstrate that primary care physician offices in Ontario discriminate against the poor by being less likely to offer them appointments. I saw an article about the study in the LA Times (Canada’s universal healthcare may not be so universal after all) and was a bit puzzled. Here’s what is said:

The researchers posed in each call as one of four types: a wealthy banker in good health, a wealthy banker with diabetes and back problems, a welfare recipient in good health, or a welfare recipient with diabetes and back problems.

Overall, the callers were 50% more likely to be offered an appointment when they posed as bankers than when they posed as welfare recipients.

‘Staff at physicians’ offices may hold negative attitudes toward this group, especially toward people receiving social assistance,’ the authors wrote. ‘Physicians have been shown to perceive patients with low socioeconomic status more negatively in terms of their personalities, abilities, behavioral tendencies and role demands.’”

Certainly the results sound bad and are consistent with the general notion that rich people get away with things while the poor get the shaft. But do Canadian primary care offices routinely try to assess the socioeconomic status of patients? It seemed odd to me.

So I read the original study (which is not linked to in the article) and my assessment is that the methodology is biased. Researchers were given scripts to use when calling the doctor’s office and were told to read them neutrally. Even if we assume they were able to be neutral (which I doubt) the language is biased in a way that throws the results and conclusions into question.

Let’s compare the wording of the two questions:

“Hi, I was just transferred to Toronto with [name of major bank], and I need a family doctor for my diabetes and back problems. Is Dr. ____ accepting new patients?”

vs.

“Hi, I’m calling ’cause my welfare worker told me that I need a family doctor for my diabetes and back problems. Is Dr. ___ accepting new patients?”

The researchers assume that the only important difference between these scripts is the information about whether the person is employed in a highly paid job or is on welfare.

I disagree. In particular, the first patient sounds like a self-motivated individual who is calling because s/he is conscientious and is making an effort to be responsible and take care of him/herself.

The second patient sounds like someone who is calling because they were told to, not because they wanted to. And why on earth does the script say “’cause” instead of because? Now imagine switching around the script so the banker is calling “’cause my wife told me I had to” and the second calls to say they needed a doctor and doesn’t make it sound like someone else told them to do so.

My guess is that the main driver of the results is that office staff are giving priority to a patient who is motivated to show up for appointments and be compliant with therapy rather than one who sounds like they’re calling just so they can tell their welfare worker that they did what they were told. If the caller hadn’t told the office of their profession or welfare status I doubt the office would have raised it. 

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The Health Business Blog is on vacation this week. Here’s a rerun of a post that originally appeared a year ago.

Health plans have realized for quite some time that the widespread practice of scheduled C-sections and induced labor before the end of 39 weeks of pregnancy is an expensive proposition. Even babies born a week or two early have a significantly higher chance of being admitted to neonatal intensive care units, having difficulty breathing and experiencing bloodstream infections. Such births are surprisingly common. In 2010 about 17 percent of babies were delivered at 37-39 weeks without a medical reason.

The Leapfrog Group. March of Dimes and American College of Obstetricians and Gynecologists has taken the initiative to try to address this issue by getting the word out and having hospitals set performance. They’ve decided there’s no reason for hospitals to have more than 5 percent of births in the early delivery/no medical reason category, and have asked hospitals to report their results.

The good news is that it seems to be working. The rate dropped from 17 percent to 14 percent from 2010 to 2011, according to newly published figures.  More than 700 hundred hospitals voluntarily reported their rates to Leapfrog. It’s fascinating to scroll through and see the variability. A good number of hospitals are at or below the 5 percent target while some others are way up in the 20 to 30+ percent range. That can’t be random variation.

So why are these medically unnecessary early births occurring? Childbirth Connection has a good summary:

• Women’s lack of knowledge about the risks, benefits, and appropriate use of labor induction
• Lack of shared decision making
• A perception among women, caregivers and hospital administrators that induction is convenient and cost-effective
• Frequent use of screening tests at the end of pregnancy, despite lack of evidence of improved outcomes
• A belief that the best way to manage risks in pregnancy is to deliver the baby

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Concerns are emerging that the adoption of electronic health records is leading to inappropriate increases in billings to payers, including Medicare, and that these higher billings could undermine or even overwhelm any cost savings generated by the digitization of providers. The concerns are legitimate but overall I’m not worried about this phenomenon, at least in the long term.

Here are the key issues:

• It didn’t take long for some physicians to figure out that they could essentially use the EHR to cut and paste records from a patient’s past visit or even from another patient’s records. As a result the record is much more thorough than it would have been otherwise and may describe more billable services than were actually performed.  This practice has been termed “cloning.”
• A second issue –as documented in the Center for Public Integrity’s Cracking the Codes– is that providers have been finding ways to bill Medicare more intensively for the same level of actual services. This has been going on for 10 years or more, but is apparently being accelerated by EHR adoption.

My take is as follows:

• The first issue is a transient one. Sure, some doctors found a lazy, seemingly clever way to save time and maybe make more money. But this practice is bad medicine and a flat out abuse of the system. To me it’s not so different from a doctor who reuses a disposable needle. They should only need to be told once that this is unacceptable. With EHRs it might take a bit of time to work out the norms and protocols to avoid cloning, but it will have to happen. Risk managers will insist on it for one thing. For another, one of the good things about a computer is that it can generate an audit trail. The cutting and pasting can be detected and flagged electronically, if not by the current generation of EHRs then by the next generation of fraud detection software. And patients will be angry if they find out this is happening to their records, and will increasingly vote with their feet.
• The second issue is only partly a function of the EHR. The bigger issue is the way billing is done. First, if providers can find a way to better document the work they are actually doing, then it’s reasonable for them to take advantage of that and bill for whatever’s allowable. Being able to fully bill acts an extra incentive for EHR adoption, above and beyond the Meaningful Use incentives. As long as the extra documentation for billing is the result of more robust clinical documentation (of work that is actually performed) then I’m all for it, because that clinical documentation could be useful for quality improvement. Of course, some of the billing is illegitimate, and again should be tracked down and disallowed.
• Finally, this controversy sheds more light on the limitations of fee-for-service medicine, where doing more things to a patient results in higher pay. If concerns about billing games help accelerate the shift away from fee-for-service then I’m all for it.